Farshid Yazdi MD
Faculty Peer Reviewed
In America, we are quickly coming upon a moment in history that will likely affect us for decades to come. A recent article in the New York Times describes the upcoming health care bill as one that will transform our health care system. President Obama has vowed to have these bills passed before the summer sessions end, but some in Congress are apprehensive about releasing such a major bill so quickly. With 45 million Americans lacking health care coverage, the bills proposed thus far will not slow the growth for health care spending and will likely increase the size, scope, and role of the government in making health care decisions. There will also likely be a need to increase taxes. As our population ages, the budget needed even 10 years from now will be much more than at present. The research will also need to reflect this trend, which, flipping through the journals this week is plain to see.
Osteoarthritis (OA) is a problem affecting many aging patients. This week in the British Medical Journal, a group of researchers elaborated on recent studies that proton pump inhibitor (PPI) therapy is beneficial when used in conjunction with NSAID or COX-2 therapy for OA. They found that it can be cost effective to prescribe the PPI when weighing quality of life against potential adverse gastrointestinal and cardiovascular events and concluded that for patients at low cardiovascular risk, a COX-2 inhibitor plus a PPI is the most cost-effective therapy for OA.
In other arthritis news, Smolen et al published a study this week showing that in patients with rheumatoid arthritis (RA), when treatment with one TNF-α inhibitor fails, a different agent of the same drug class may be effective. In this double-blind study, 461 patients were given placebo (n= 155) or golimumab, a TNF-α inhibitor, at either 50mg (n= 153), or 100 mg (n= 153) via subcutaneous injection every 4 weeks for 19 months, and were asked to report on symptoms. After 14 weeks, 18% of patients on placebo, 35% of patients on 50 mg, and 38% on 100 mg of golimumab achieved improved symptoms. After 16 weeks, serious adverse events were found in 7%, 5% and 4% in the respective groups. The authors concluded that golimumab was effective in reducing signs and symptoms of rheumatoid arthritis in patients who had active disease and had previously been unsuccessfully treated with TNF- α inhibitors.
With an aging population, diseases more prevalent following menopause become a major concern. In JAMA this week, a prospective cohort study looking at ovarian cancer rates in Danish women concluded that hormone therapy for peri- and postmenopausal women is, in fact, linked to the cancer. Over 900,000 women between 50 and 79 years of age were followed for 10 years. They found that regardless of type of hormone therapy, route of administration, dosage or progestin type there was an increased risk of ovarian cancer. Compared to women who never took hormone therapy, women who did were 1.38 times more likely to develop cancer. They also looked at how risk declined after stopping hormone therapy. Zero to 2 years after stopping hormone therapy, the risk ratio dropped to 1.22. Two to 4 years after stopping, the ratio dropped to 0.98, and after more than 4-6 years, the risk ratio dropped to 0.72. Essentially, the authors calculated 1 extra ovarian cancer for every 8,300 women taking hormone therapy each year. This data continues to point to a need to be cautious with our use of hormone therapy for women entering their postmenopausal state.
In cardiovascular health this week, researchers at UNC-Chapel Hill illustrated the positive effect of actively commuting to work by walking or bike riding. They included over 2,000 patients from their Coronary Artery Risk Development in Young Adults (CARDIA) study to look at how actively commuting affects BMI, blood pressure, lipids, and glucose and insulin levels. They found that obesity risk was cut in half in those who actively walked to work, triglyceride levels were 12% lower, mean fasting insulin was 14% lower, and diastolic blood pressure was lower by 1.67. So just a little something to suggest to your patient that needs a little improvement in or maintenance of their cardiovascular health.
Colon cancer screening is another topic that cannot be avoiding when discussing our aging population. Capsule endoscopy is often advertized to our patients as a colon cancer screening modality that is less invasive and requires no sedation. Published in the NEJM this week, a study looking at the ability of capsule endoscopy to detect advanced adenoma in the colon found a sensitivity of 73% and specificity of 79% (dependant on colon cleanliness) of capsule endoscopy. This study provides important data to help us make a clinical decision on whether to order this test versus a colonoscopy, which at the moment is and should remain the gold standard.
Other cancer news making headlines is a study released in JAMA this week looking at prognosis of gliomas in patients based on the presence of certain genetic mutations. The authors looked at the genomic and clinical profiles of 501 patients with gliomas and found that certain genetic alterations led to poorer prognoses. A risk-scoring model was developed based on 7 landscape genes, whereby 0-2 alterations led to an increase in deaths of 49.24 per 100 person-years. The more high-risk group, with 5-7 alterations in these genes, was calculated to have 79.56 deaths per 100 person-years (with the hazard ratio calculated at 1.63). These findings suggest patient prognosis can be determined in gliomas and glioblastomas with a genetic test, resulting in possible improved management of the diseases.
With a health care system on the verge of major changes in the coming months and the cost of health care continuing to rise, it is essential to focus on the aging population, an important and growing part of our nation. As outlined in the articles discussed above, a focus on early detection and prevention of disease will be the cornerstone of improved health care and the lowering of health care costs as we move forward.
Dr. Yazdi is a 1st year internal medicine resident at NYU Medical Center.
Reviewed by Danise Schiliro-Chuang MD, Contributing Editor, Clinical Correlations
References:
1. Pear R and Herszenhorn D. The New York Times. July 17, 2009.
2. Latimer N, Lord J, Grant R, et al. Cost effectiveness of COX 2 selective inhibitors and traditional NSAIDs alone or in combination with a proton pump inhibitor for people with osteoarthritis. BMJ. 2009;339:b2538.
3. Smolen J, Kay J, Doyle M, et al. Golimumab in patients with active rheumatoid arthritis after treatment with tumour necrosis factor α inhibitors (GO-AFTER study): a multicentre, randomised, double-blind, placebo-controlled, phase III trial. The Lancet. 2009;374(9685):210-221.
4. Morch L, Lokkegaard E, Andreasen A, et al. Hormone Therapy and Ovarian Cancer. JAMA. 2009;302(3):298-305.
5. Gordon-Larsen P, Boone-Heinonen J, Sidney S, et al. Active Commuting and Cardiovascular Disease Risk: The CARDIA Study. Arch Intern Med. 2009;169(13):1216-1223.
6. Van Gossum A, Navas M, Fernandez-Urien I, et al. Capsule Endoscopy versus Colonoscopy for the detection of polyps and cancer. NEJM. 2009;361:264-270.
7. Bredel M, Scholtens D, Harsh G, et al. A Network Model of a Cooperative Genetic Landscape in Brain Tumors. JAMA. 2009;302(3):261-275.